HomeMy WebLinkAbout15-167IDENTIFICATION NO. _� �j — 1 L-0-7
(Office Use Only)
VI11 .11V h
CITY OF IOWA CITY APPLICATION FOR TAXICAB 1 MOTORIZED PEDICAB VEHICLE DRIVER
(Police Department review must be made between 8 a.m. to 3 p.m., Monday - Friday)
410 East Washington Street
Iowa at Iowa s,2,2,40-1 826 Failure to complete the `required" information will result in denial of the application
1319) 356-SO40
(3 19) 356-5497 FAX
First Middle Last
1. Name (REQUIRED) S ct rv, sw � q�o, M 14
2. Address (REQUIRED) 16:0 P, R,,AtA\ — \ L \ to w c, C , s 22 6-
3. Contact Information (REQUIRED) Email:3t CSM Cell Phone 21 S S ( cl 3 o F2
(All written communic/ation sent via email)
4a. Chauffeur's License expiration date (REQUIRED) G I 0 1 12 d I
b. Taxicab Business Name (REQUIRED) - w a ,n
5. Prior experience in transportation of passengers: _L. -I_
6. Have you ever been arrested / charged with any misdemeanors and/or felonies in this State or elsewhere? ..IV Z
Type of offense
What happened to the charge? (Circle one)
Where
When
Convicted Dismissed Deferred Suspended Plead Guilty Other
7. Have you been arrested / charged with any traffic offenses in the last five years?
Type of offense Where When
1 A- t�8 II
.pp pyp �u?(
What happened
tto the charge. (Circle one)
Convicted Dismissed Deferred Suspended Plead Guilty Other
8. Has your driver's license or chauffeur's license been suspended or revoked in the last five years?
Type of offense
Where
9. Have you ever applied to be an Iowa City taxi driver using a different name? If yes, please
DEPARTMENT OF CRIMINAL INVESTIGATION (DCI) REPORT AND ST.
DRIVING RECORD MUST ACCOMPANY THIS APPLICATION FOR POLIO
When
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You must apply for an individual Department of Criminal Investigation Report (form available upon request).
(SECOND PAGE FOR REQUIRED SIGNATURE AND NOTARY)
02/2015
APPLICATION FOR TAXICAB VEHICLE DRIVER
Page 2
I hereby certify that I have issued to me by the Iowa Department of Transportation a valid Chauffeur's license number
S S T) 3q 1 �4 issued on 12 I I expiring onL o { . I understand that if I
falsely answer any questions in this application, that this application may be denied. agree that in making this application, I
consent to allow agents or employees of the City of Iowa City, Iowa, in their discretion, to examine any and all records and
documents relating to this application, and I further agree that, if authorization to be a taxicab driver is granted, to comply at all
times with all of the provisions of Title 5, Chapter 2, of the City Code. (Needs to be signed in front of a Notary Public)
_� / i
Signature of Applicant�� _= �: �- Date
STATE OF IOWA )
COUNTY OF JOHNSON )
Subscribed and sworn to before me by1JX-A on this i day of
J''4
VO �
VJENDY 5. MAYER
Commission Numow 728428
Public
I have reviewed this application, DCI report, and the State certified driving record of this applicant and have determined that
there is no information which would indicate that the issuance would be detrimental to the safety, health or welfare of resi-
dents of the City of Iowa City (Title 5, Chapter 2, City Code).
Expiration date of Chauffeur's license (� 7
Signature oT Cfiief or designee
AFTER APPROVAL BY THE CITY CLERK YOU ARE AUTHORIZED TO DRIVE A TAXICAB IN IOWA CITY FOR NO
MORE THAN ONE YEAR FROM THE DATE LISTED BELOW.
if�i�
Sign re of City Clerk or designee
Approved application
DCI report
State certified driving record
Website update
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Date
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Office Use Only
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Clerkf AXIDRNBA GE PPL52014amended.DOC 03/2015
Fug.l3l 201h I I : "AMCJor' i v of Criminal Investigation 00/1820 s 16N.o299220,P.. 1/2„002
STATE OF IOWA
Crifttinal lj'is't-ory RCC(irff Cheok
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Ta: Iowa DiwQsiun of Criminal lnvegtiga{ion
3uppurf Operatiuns Hurcau, 1"Clam
215 r;. 71h ,5'treel
Da Aloincs� lora 50319
(515) 72S-6666
(t'15)125-6080 J."
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ph m�e: 37 9356-5041
Far:
319-356•^— 54gj - --
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No ”' Crimiltal History Record found wa,ilh DC7
]ua�a C`,rimi)nal His(a'y Recurd attacheJ, DCJ
---.__—_�------_DCI iniiials,_,,.�
DCI -77 (08/2i/10) - —
Received Time Aug.12, 2015 11:49AM No.2869
ARTS
VwAv.iowodot,gov
SMARTER I SIMPLEF I (0TOIAEF € iRM'J�
Inquiry Date: 8/18/2015
Page 1 of 1
Office of Driver Services
PO Bor, 9204 Des Moines. IA 50306-9204
Pho^e: 515-244-9124 1 800-532-;121 1 Fax: 515-239-1837
www.owadol.gor
Certified Abstract of Driving Record
Name:
Amin, Samir Taha
Address:
2608 BARTELT RD APT
Audit #:
1C
City/State:
IOWA CITY, IA
Expiration
522462730
DL/ID #:
255DD3914 (IA)
Class:
D
Audit #:
5708685
Issue Date:
12/28/2011
Expiration
01/01/2017
Date:
IA
Endorsements: 3
Mailing Address: 2608 BARTELT RD APT Restrictions: NONE
1C Date of Birth: 1/1/1963
Mailing City/State: IOWA CM, IA Sex: M
522462730
History Information
Convictions
Customer #:
4327702
ID Status:
None
DL Status:
VAL
CDL Status:
None
CDL Cert
None
Status:
IA
CDL Med
None
Status:
Speed
Restriction
None
Supplement:
02/04/2014
Citation Date
Conviction Date
ACD
Explanation
County
JUR
01/08/2011
02/11/2011
M14
Fail to Obey Traffic Sign/Signal
Johnson
IA
09/01/2011
10/02/2011
S92
Speed
Black Hawk
IA
09/29/2013
02/04/2014
N50
Improper Turn
Johnson
IA
Name: Amin, Samir Taha DL/ID: 255DD3914
Pursuant to Iowa Code §321.10, I, Kim Snook, Director of Office of Driver Services, Iowa Department of Transportation, do hereby
certify that I am the custodian of the records held by the Office of Driver Services, that this is a true and accurate copy of an official
record currently in the custody of said office, and that I have been authorized by the Director of the Iowa Department of
Transportation to so certify.
In witness whereof, I have caused my signature and the seal of the Department to be set upon this document, at Ankeny, Iowa this
date:
. """•���"44
8/18/2015
IOWA -sf
D. 0. T.;Sf
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071
Office of Driver Services
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Iowa Department of Transportation
Name: Amin, Samir Taha DL/ID: 255DD3914
8/18/2015